As a newborn this child underwent an arterial switch operation for transposition of the great arteries. The result of the operation was good. The child has bradycardia. A mild þ40 þ45 mmHg anastomotic stenosis of the pulmonary artery, and minor shunt through the aortic cusp on echocardiography. On auscultation a third-degree systolic murmur is heard that matches mild stenosis. Aortic valve regurgitation is so small that it is not heard as a murmur. Note also S4. The fourth heart sound suggests mild failure of the left ventricle. This finding is explained by the technique employed in the switch operation where the coronary arteries have to be transferred from the pulmonary position to the root of the neoaorta. Age 9.5 years, height 131 cm, weight 26 kg. Area of auscultation: left third ic (LIC3).